Addictive Medication David Cook University of Alberta
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The agenda this afternoon 1:45pm-2:30pmIntroduction to
addiction, Opioids 2:30pm-2:45pmBreak 2:45pm-3:30pmBenzodiazepines
3:30pm-3:45pmBreak 3:45pm-4:10pmMethylphenidate etc
4:10pm-4:30pmQuestions
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Some definitions Drug use taking something Drug use taking
something Drug abuse taking something that results in negative
consequences Drug abuse taking something that results in negative
consequences Drug addiction continued drug use where it is
blindingly obvious that drug use is causing problems with work,
home, family life, friendships, spirituality etc. Drug addiction
continued drug use where it is blindingly obvious that drug use is
causing problems with work, home, family life, friendships,
spirituality etc.
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Abstinence syndrome (Withdrawal syndrome, previously called
physical dependence) Abstinence syndrome (Withdrawal syndrome,
previously called physical dependence) A situation in which the
body has changed so that it behaves more normally in the presence
of the drug than its absence. That is deprive the person of the
drug and they get sick. A situation in which the body has changed
so that it behaves more normally in the presence of the drug than
its absence. That is deprive the person of the drug and they get
sick. Tolerance Tolerance A situation where the user needs
progressively more of the drug to get the same effect A situation
where the user needs progressively more of the drug to get the same
effect
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There are reward pathways in the brain Stimulation of those
nerves makes us feel good Stimulation of those nerves makes us feel
good The pathway exists to reward us for actions that are good for
the individual or the species (eating, sex etc.) The pathway exists
to reward us for actions that are good for the individual or the
species (eating, sex etc.) When we feel good we want to repeat the
experience When we feel good we want to repeat the experience We
easily become dependent on behaviours that stimulate this pathway
(gambling, music etc.) We easily become dependent on behaviours
that stimulate this pathway (gambling, music etc.)
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The drugs simply activate the reward pathway! GABA (Alcohol,
Benzodiazepines etc.) Opiods (Heroin etc.) Dopamine (Amphetamines
and Cocaine) Acetylcholine (Nicotine) The drugs work at the most
fundamental survival level The drugs work at the most fundamental
survival level
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Consequences of repeated drug use are: The pathway starts to
turn itself off! Increased dose to obtain the same effect Reduction
or absence in the effect of normal reward stimuli After abstention
NOTHING activates the pathway! After abstention there will be an
abnormal emphasis on getting the reward pathway working
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Key point about brain chemistry Attempts to abstain from drugs
are difficult because the user has rewired the brain. Expecting the
user to be able to stop drug use and immediately regain normal
attitudes is unrealistic. The healing process is real and may be
prolonged. Attempts to abstain from drugs are difficult because the
user has rewired the brain. Expecting the user to be able to stop
drug use and immediately regain normal attitudes is unrealistic.
The healing process is real and may be prolonged.
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Narcotics, Opiates, Opioids, Narcotics is an old term for these
drugs, often used for legal purposes Narcotics is an old term for
these drugs, often used for legal purposes Opiates are compounds
that are chemically related to morphine Opiates are compounds that
are chemically related to morphine Opioids are ANY compounds that
interact with the opioid receptor Opioids are ANY compounds that
interact with the opioid receptor
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Opium poppy Photo: Opium.Org Photo: CIA
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Scraping off the resin Photo: CIA
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Opium gum Photo: CIA
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Heroin
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Where does it come from?
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Opium/Morphine/Heroin These are by far the best pain relieving
drugs we have! These are by far the best pain relieving drugs we
have! They have been known for more than 3000 years as agents that
relieve pain, cough and diarrhoea They have been known for more
than 3000 years as agents that relieve pain, cough and diarrhoea
Addiction to the drugs has been known for almost as long as the
pain relieving properties have been known Addiction to the drugs
has been known for almost as long as the pain relieving properties
have been known
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Pain What causes it What causes it How the body responds to it
How the body responds to it How we control it How we control
it
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Sir William Osler The greatest service a physician can render
to his patients is in the alleviation of pain
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Pain has two components: 1 The pain itself which results from
nerves near the site of the pain transmitting information. The pain
itself which results from nerves near the site of the pain
transmitting information.
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Brain? This is your big toe. You just stubbed me, you
idiot!
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There is a threshold Not all perceived touch is painful Not all
perceived touch is painful Not all warmth is experienced as a burn
Not all warmth is experienced as a burn Injury releases
prostaglandins - chemicals that AMPLIFY the pain sensation Injury
releases prostaglandins - chemicals that AMPLIFY the pain sensation
If we block the production of prostaglandins, the pain will recede
to levels that are not experienced as pain. If we block the
production of prostaglandins, the pain will recede to levels that
are not experienced as pain. This is how Aspirin and Tylenol work
This is how Aspirin and Tylenol work
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The second part is how the pain is interpreted. This is MUCH
more complicated!
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It hurts!
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It hurts but its worth it!
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It hurts but it is a profound religious experience
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It hurts but it turns me on!
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Pain is sensed by nerve endings Two sorts of pain fibres that
carry messages to the central nervous sytem: Two sorts of pain
fibres that carry messages to the central nervous sytem: A fibres
very fast and trigger the reflex that makes us move away from the
pain in less than 0.5 sec! A fibres very fast and trigger the
reflex that makes us move away from the pain in less than 0.5 sec!
C fibres are slower but convey it HURTS takes about 2 seconds C
fibres are slower but convey it HURTS takes about 2 seconds Pain
hits us twice! Pain hits us twice! Neuropathic pain arises from
nerve damage Neuropathic pain arises from nerve damage
Slide 29
The fibres do NOT go straight to the brain They go to a part of
the spinal cord that is called the Dorsal horn via the dorsal root
ganglia. The dorsal horn They go to a part of the spinal cord that
is called the Dorsal horn via the dorsal root ganglia. The dorsal
horn Organizes the reflex motor response Organizes the reflex motor
response Transmits the message to the brain that something painful
has happened via the ASCENDING PATHWAYS Transmits the message to
the brain that something painful has happened via the ASCENDING
PATHWAYS Face and neck nerves go to the brainstem Face and neck
nerves go to the brainstem
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The dorsal horn can get confused The structure gets multiple
inputs from different sites. Usually it can sort them out, but
sometimes it makes a mistake. The structure gets multiple inputs
from different sites. Usually it can sort them out, but sometimes
it makes a mistake. Referred pain Referred pain It can also become
sensitized chronic pain It can also become sensitized chronic
pain
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How is the information sent onwards? There are lots of chemical
messengers in the dorsal horn. Opioid receptors block the
transmission of information. There are lots of chemical messengers
in the dorsal horn. Opioid receptors block the transmission of
information. Thus drugs like codeine, morphine and Demerol have a
direct pain-relieving effect Thus drugs like codeine, morphine and
Demerol have a direct pain-relieving effect This is just part of
the story This is just part of the story
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The brain can modulate the pain sensation The brain sends
DESCENDING nerves to the dorsal horn. The brain sends DESCENDING
nerves to the dorsal horn. These nerves are only stimulated by very
unusual situations, BUT if they are stimulated, they block the
upward transmission of information. These nerves are only
stimulated by very unusual situations, BUT if they are stimulated,
they block the upward transmission of information. Opioid receptors
are key Opioid receptors are key This is another way in which
codeine etc work. This is another way in which codeine etc
work.
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How does the brain convert the information into pain We really
dont know! We really dont know!
Tylenol-3, 292 etc. Why? Peaceful pleasant mild heroin-like.
Often arises from prescription Why? Peaceful pleasant mild
heroin-like. Often arises from prescription Acute risks? Minimal,
although combination with other drugs may cause problems Acute
risks? Minimal, although combination with other drugs may cause
problems Long term risks? Significant dependence that is difficult
to shake. Constipation, difficulty in providing good pain
management Long term risks? Significant dependence that is
difficult to shake. Constipation, difficulty in providing good pain
management Real risks? Dependence Real risks? Dependence
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Opioid withdrawal Painful but not life-threatening Painful but
not life-threatening Craving, Restlessness, increased pain
sensitivity, nausea, cramps, muscle aches, sleeplessness, anxiety
Craving, Restlessness, increased pain sensitivity, nausea, cramps,
muscle aches, sleeplessness, anxiety Pupillary dilation, sweating,
hair stands on end (cold turkey), increased heart rate, diarrhoea,
fever Pupillary dilation, sweating, hair stands on end (cold
turkey), increased heart rate, diarrhoea, fever Triggered by
antagonists Triggered by antagonists
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Issues around opioid use In-patient use is almost never
responsible for addiction In-patient use is almost never
responsible for addiction Outpatient use is a different story there
are lots of excuses for long-term use Outpatient use is a different
story there are lots of excuses for long-term use Things that are
probably not helped a great deal include: Things that are probably
not helped a great deal include: Fibromyalgia Fibromyalgia Low back
pain Low back pain Headache Headache BUT there are a few conditions
in which long-term opioid use may be the best option BUT there are
a few conditions in which long-term opioid use may be the best
option
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Break time!
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Anxiety and insomnia Anxiety is a useful thing, but may
sometimes became disabling. Anxiety is a useful thing, but may
sometimes became disabling. On the basis of the effects of drugs,
presumably there are problems involving the GABA receptor system,
but we are not really sure On the basis of the effects of drugs,
presumably there are problems involving the GABA receptor system,
but we are not really sure For most people the management of
long-term disabling anxiety involves psychotherapy For most people
the management of long-term disabling anxiety involves
psychotherapy Drug use is usually a short-term solution only Drug
use is usually a short-term solution only
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Sleep We know a lot about sleep, but we still do not know how
it works and why we need it We know a lot about sleep, but we still
do not know how it works and why we need it Generally the body
takes what sleep it needs Generally the body takes what sleep it
needs A cycle starts in which something causes an interruption of
normal sleep and this is followed by worry about sleep followed by
further insomnia. A pattern of chronic arousal results. A cycle
starts in which something causes an interruption of normal sleep
and this is followed by worry about sleep followed by further
insomnia. A pattern of chronic arousal results. Medication produces
sleep, but it is not a normal sleep Medication produces sleep, but
it is not a normal sleep
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Non-drug management of sleep disorder Make sure that it it
really is happening most insomniacs underestimate the time spent
asleep Make sure that it it really is happening most insomniacs
underestimate the time spent asleep Caffeine no caffeinated
beverages after 2:00pm Caffeine no caffeinated beverages after
2:00pm Exercise Exercise Warm drink (not caffeinated!) Warm drink
(not caffeinated!) Acceptance of changed sleep pattern Acceptance
of changed sleep pattern Relaxation exercises Relaxation exercises
Do not use bedroom for reading, TV etc Do not use bedroom for
reading, TV etc Develop a routine Develop a routine
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Sedative-hypnotic drugs Benzodiazepines:Valium, Librium,
Ativan, Serax, Xanax, Lectopam, Versed, Tranxene, Dalmane, Mogadon,
Restoril, Halcion Benzodiazepines:Valium, Librium, Ativan, Serax,
Xanax, Lectopam, Versed, Tranxene, Dalmane, Mogadon, Restoril,
Halcion Others: Imovane, Equanil, 282 MEPs Others: Imovane,
Equanil, 282 MEPs All these drugs have the potential to cause
addiction All these drugs have the potential to cause
addiction
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ALL SEDATIVE/HYPNOTICS All work at the GABA receptor and all
create the following series of events: All work at the GABA
receptor and all create the following series of events: Decreased
anxiety Decreased anxiety Excitement/Disinhibition
Excitement/Disinhibition Sedation Sedation Sleep Sleep Anesthesia
Anesthesia Coma Coma Respiratory depression Respiratory depression
Death Death
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ALL these drugs Produce rebound insomnia Produce rebound
insomnia Produce somnolence, impair driving and in overdose depress
breathing. Produce somnolence, impair driving and in overdose
depress breathing. Interact with alcohol and with each other to
produce effects which are greater. Interact with alcohol and with
each other to produce effects which are greater. Can impair memory,
particularly in the elderly Can impair memory, particularly in the
elderly Are relatively free of damage to heart, liver, blood
pressure etc. Are relatively free of damage to heart, liver, blood
pressure etc. Make it easier to survive anxiety and stress, at the
cost of making everything bland. Make it easier to survive anxiety
and stress, at the cost of making everything bland. Medically
should only be used for longer than one month in rare cases.
Medically should only be used for longer than one month in rare
cases.
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Other uses Sedation prior to surgery (no risk of addiction!)
Sedation prior to surgery (no risk of addiction!) Sedation in the
ER after stimulant overdose Sedation in the ER after stimulant
overdose Clonazepam (Klonopin) is used in epilepsy and sometimes in
mania all the benzodiazepines have some anti-seizure activity
Clonazepam (Klonopin) is used in epilepsy and sometimes in mania
all the benzodiazepines have some anti-seizure activity
Chlordiazepoxide (Librium) is used to suppress withdrawal syndrome
in alcoholics Chlordiazepoxide (Librium) is used to suppress
withdrawal syndrome in alcoholics As muscle relaxants As muscle
relaxants
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Issues around benzodiazepine use The drugs are over-used,
particularly in the long term management of anxiety The drugs are
over-used, particularly in the long term management of anxiety They
are sometimes used because the doctor feels a need to do something
to alleviate the patient's distress; the patient may be better off
to change their circumstances They are sometimes used because the
doctor feels a need to do something to alleviate the patient's
distress; the patient may be better off to change their
circumstances Withdrawal is difficult use a physician, because
seizures can occur Withdrawal is difficult use a physician, because
seizures can occur The drugs do have a street value The drugs do
have a street value
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You deserve a break!
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Stimulants - ADHD The drugs are methylphenidate (Ritalin,
Concerta, Attendade, which is optically pure d- methylphenidate),
amphetamines (Dexedrine, Adderal, not available in Canada since Feb
2005). The drugs are methylphenidate (Ritalin, Concerta, Attendade,
which is optically pure d- methylphenidate), amphetamines
(Dexedrine, Adderal, not available in Canada since Feb 2005). They
are used for: They are used for: ADHD ADHD Narcolepsy Narcolepsy
All have a street value All have a street value
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ADHD Incidence is 3-5% in children. In about 80% of thes,
problems continue into the teens, and about half have problems into
adulthood. Incidence is 3-5% in children. In about 80% of thes,
problems continue into the teens, and about half have problems into
adulthood. If one plots activity vs number of children: If one
plots activity vs number of children:
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ADHD Poor attention span Poor attention span
Opposition-defiance disorder Opposition-defiance disorder Conduct
disorder Conduct disorder Often diagnosed by teachers Often
diagnosed by teachers Often over-diagnosed Often over-diagnosed A
child psychiatrist can make sensible decisions A child psychiatrist
can make sensible decisions Resistance to authority is not, by
itself a sign of ADHD Resistance to authority is not, by itself a
sign of ADHD
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ADHD The cause is largely unknown The cause is largely unknown
There are significant differences in the brains of kids with ADHD
There are significant differences in the brains of kids with ADHD
Treatment tends to normalize the brain picture Treatment tends to
normalize the brain picture About 95% of ADHD patients improve with
medication About 95% of ADHD patients improve with medication There
are strong opinions on the value of medication, often held by
people with no experience of the condition and no knowledge of the
literature. There are strong opinions on the value of medication,
often held by people with no experience of the condition and no
knowledge of the literature.
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What do stimulants do? The help the patient to concentrate The
help the patient to concentrate They improve tolerance for boredom
and increase the chances of finishing a task They improve tolerance
for boredom and increase the chances of finishing a task They do
not help learning as such They do not help learning as such They
improve relationships between the patient and his/her teacher,
parents and peers They improve relationships between the patient
and his/her teacher, parents and peers The medicine is usually
well-tolerated The medicine is usually well-tolerated
Slide 56
Medication Complementary and alternative therapies have usually
not been subjected to appropriate testing. Complementary and
alternative therapies have usually not been subjected to
appropriate testing. Behavioural therapy along with medication
seems to give the best results, followed closely by medication
alone. Behavioural or community psychotherapy or guidance are less
successful. Behavioural therapy along with medication seems to give
the best results, followed closely by medication alone. Behavioural
or community psychotherapy or guidance are less successful. That
said, there are plenty of things parents and others can do to help
the child. That said, there are plenty of things parents and others
can do to help the child.
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Adverse effects Reduced appetite during the day, but no
evidence of long-term growth retardation Reduced appetite during
the day, but no evidence of long-term growth retardation Difficulty
falling asleep (often resolved by using a lower dose) Difficulty
falling asleep (often resolved by using a lower dose) VERY RARE
cardiovascular problems, but the drugs do elevate blood pressure
and heart rate. VERY RARE cardiovascular problems, but the drugs do
elevate blood pressure and heart rate. Addiction rates in treated
patients are lower than in untreated controls Addiction rates in
treated patients are lower than in untreated controls In one study
25% of those receiving the drugs had diverted the material onto the
street, at least once In one study 25% of those receiving the drugs
had diverted the material onto the street, at least once
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Addiction True addiction in people using the drugs for ADHD is
very rare True addiction in people using the drugs for ADHD is very
rare If the drugs are taken recreationally by someone who does not
have ADHD, they have effects like amphetamines If the drugs are
taken recreationally by someone who does not have ADHD, they have
effects like amphetamines Ritalin used to be combined with the
opioid pentazocine (Talwin) to give Ts & Rs or Poor mans
heroin. Talwin is no longer widely available in an injectable form,
but we still see this combination on occasion Ritalin used to be
combined with the opioid pentazocine (Talwin) to give Ts & Rs
or Poor mans heroin. Talwin is no longer widely available in an
injectable form, but we still see this combination on occasion
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Client issues around ADHD Make sure that the patient really
does have ADHD Make sure that the patient really does have ADHD
Support the use of stimulants if the child does have ADHD Support
the use of stimulants if the child does have ADHD Make sure the
drug is not being diverted Make sure the drug is not being diverted
Key concepts in support of the patient include emotional support
and praise, clear statements of the childs responsibility, and the
establishment of routine. Key concepts in support of the patient
include emotional support and praise, clear statements of the
childs responsibility, and the establishment of routine. Good
nutrition and healthy sleep patterns are important Good nutrition
and healthy sleep patterns are important
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Time for your questions on anything we have discussed!